PrEP -- A new tool in the PWID toolkit?

Pre-Exposure Prophylaxis (PrEP) using the antiretroviral medication emtricitibine/tenofovir approved in countries around the world is a highly effective means of reducing transmission of HIV through sexual encounters and needle sharing.
This Johns Hopkins University course PrEPares you with essential information, concepts and practical advice regarding PrEP from leaders in the field. A first of its kind learning opportunity, both providers and patients learn from the same experts through content that meets the needs of both audiences, while facilitating the opportunity for a shared community space.
Lessons for healthcare workers provide background on foundational and cutting-edge research and PrEP guidelines, how to initiate a PrEP program, clinical management and providing culturally sensitive sexual health and primary care to diverse communities.
Lessons for PrEP enthusiasts, PrEP users or the PrEP curious provide information regarding who can benefit from PrEP, how to access services, what to expect and how to stick with your PrEP program long-term.
The Association of Nurses in AIDS Care is providing 9.1 contact hours, 1.2 of which can be use towards pharmacology contact hours for this course. The Association of Nurses in AIDS Care is an approved provider of continue nursing education by the American Nurses Credentialing Center's Commission on Accreditation
OBJECTIVES:
At the conclusion of the session, the participant will be able to:
1. Describe the differences between foundational PrEP studies and demonstration projects
2. Describe the basic pharmacodynamics of tenofovir/emtricitibine including mechanism of infection prevention and time to protective concentration in mucosal tissues
3. List recommendations from PrEP for Prevention of HIV Infection in the United States clinical practice guidelines, USPHS and CDC, including initial and ongoing screening and testing
4. Describe the need for PrEP as an HIV prevention tool for priority in often stigmatized populations
5. Indicate the components for integrating PrEP services into clinical practice
6. Outline guidelines for screening and treatment of sexually transmitted infections
7. Describe how to take a thorough sexual history and to engage with clients around sex in an affirming and non-judgmental manner
8. List the baseline and follow-up laboratory monitoring required
9. Explain key aspects of patient education for HIV prevention and sexual health
10. Describe protocols for ongoing PrEP services and when to discontinue
FACULTY/ CREDENTIALS:
Jason E. Farley, PhD, MPH, ANP-BC, FAAN, Associate Professor
Johns Hopkins University School of Nursing
Chris Beyrer, MD, MPH, Professor
Johns Hopkins University Bloomberg School of Public Health
Yusuf Ariyibi, BA, Disease Intervention Specialist
Baltimore City Health Department
Joyce Jones, MD, MS, Clinical Associate
Johns Hopkins University School of Medicine
Neha Sheth Pandit, PharmD, AAHIVP, BCPS, Associate Professor
University of Maryland School of Pharmacy
Pierre-Cedric Crouch, PhD, ANP-BC, ACRN, Director of Nursing
San Francisco AIDS Foundation
Renata Arrington Sanders, MD, Assistant Professor
Johns Hopkins University School of Medicine
Jenell Coleman, MD, MPH, Associate Professor
Johns Hopkins University School of Medicine
Michele Decker, ScD, MPH, Associate Professor
Johns Hopkins University Bloomberg School of Public Health
Deborah Dunn, PA-C, MBA, Physician Assistant
Chase Brexton Health Care
Jordan White, MS, Desmond Tutu Fellow of Public Health and Human Rights
Johns Hopkins University Bloomberg School of Public Health
Gregory Lucas, MD, PhD, Professor
Johns Hopkins University School of Medicine
Demetre Daskalakis, MD, MPH, Acting Deputy Commissioner, Division of Disease Control, NYC Dept. of Health and Mental Hygiene
David Dowdy, MD, PhD, Associate Professor
Johns Hopkins University Bloomberg School of Public Health
Jessica LaRicci, PrEP Coordinator
Johns Hopkins University School of Nursing
Susan Tuddenham, MD, MPH, Assistant Professor
Johns Hopkins University School of Medicine
Joseph Cofrancesco, MD, MPH, FACP, Associate Professor of Medicine
Johns Hopkins University School of Medicine
Jill Crank, CRNP, MSN/MPH, Nurse Practitioner
Evergreen Healthcare
Paul Sacamano, MPH, ANP-BC, ACRN, PrEP Project Lead
Johns Hopkins University School of Nursing
Shima Ge, BS, PrEP Peer Navigator
Johns Hopkins University School of Nursing
ORIGINATION DATE: October 2, 2017
RENEWAL DATE:
EXPIRATION DATE: October 2. 2019
URL: https://www.coursera.org/learn/prep/
HARDWARE/SOFTWARE: Computer Hardware; Internet connection; Browser
MATERIALS: None
TARGET AUDIENCE: physicians, physician assistants, nurse practitioners, registered nurses, pharmacists, health education specialists, public health workers, social workers, case managers
PREREQUISITES: None
FORMAT: These seminars are enduring video presentations with online discussion forum and resources.
CONTACT INFORMATION: Office of The REACH Initiative, Johns Hopkins University School of Nursing (888) 788-7737
ACCREDITATION STATEMENTS:
CME activities with Joint Providers: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint providership of the Centers for Disease Control and Prevention and Johns Hopkins University School of Nursing. The Centers for Disease Control and Prevention is accredited by the (ACCME®) to provide medical education for physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
The Centers for Disease Control and Prevention designates this enduring material for a maximum of 10.75 AMA PRA Category 1 Credits™.
CEU: The Centers for Disease Control and Prevention is authorized by IACET to offer 1.1 CEU's for this program.
CECH: Sponsored by the Centers for Disease Control and Prevention, a designated provider of continuing education contact hours (CECH) in health education by the National Commission for Health Education Credentialing, Inc. This program is designated for Certified Health Education Specialists (CHES) and/or Master Certified Health Education Specialists (MCHES) to receive up to 10.5 total Category I continuing education contact hours. Maximum advanced level continuing education contact hours available are 0. CDC provider number 98614.
The Centers for Disease Control and Prevention is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education.
This program is a designated event for pharmacists to receive 1.05 CEUs in pharmacy education. The Universal Activity Number is 0387-9999-17-232-H01-P.
Category: This activity has been designated as Knowledge-Based.
Once credit is claimed, an unofficial statement of credit is immediately available on TCEOnline. Official credit will be uploaded within 60 days on the NABP/CPE Monitor.
For Certified Public Health Professionals (CPH)
The Centers for Disease Control and Prevention is a pre-approved provider of Certified in Public Health (CPH) recertification credits and is authorized to offer 11 CPH recertification credits for this program.
CDC is an approved provider of CPH Recertification Credits by the National Board of Public Health Examiners. Effective October 1, 2013, the National Board of Public Health Examiners (NBPHE) accepts continuing education units (CEU) for CPH recertification credits from CDC. Please select CEU as your choice for continuing education when registering for a course on TCEOnline. Learners seeking CPH should use the guidelines provided by the NBPHE for calculating recertification credits. For assistance please contact NBPHE at http://www.NBPHE.org.
DISCLOSURE: In compliance with continuing education requirements, all presenters must disclose any financial or other associations with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters as well as any use of unlabeled product(s) or product(s) under investigational use.
CDC, our planners, our content experts and their spouses/partners wish to disclose they have no financial interests or other relationships with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters with the exception of Dr. Jason Farley and he wishes to disclose that he received grant from Gilead. Planning committee discussed conflict of interest with Dr. Farley to ensure there is no bias.
Content will not include any discussion of the unlabeled use of a product or a product under investigational use with the exception of Dr. Arrington Sander’s discussion of PrEP for adolescents, PrEP is not approved for adolescents < 18 years old; and Dr. Tuddenham’s discussion of STI screening, she will be discussing extra genital screening with NAAT currently recommended by CDC.
CDC did not accept commercial support for this continuing education activity.
To receive continuing education (CE):
Complete the activity
Complete the Evaluation at www.cdc.gov/TCEOnline
Pass the posttest at 80% at www.cdc.gov/TCEOnline
FEES: No fees are charged for CDC’s CE activities.

IR

My name is Ivan Rivera this online training really help me even more to provide more powerful information to my clients, as a PrEp Navigator in NYC.

JS

Mar 06, 2019

Filled StarFilled StarFilled StarFilled StarFilled Star

Great course that allows clinical understanding of PrEP, how and why it works!!

从本节课中

Module 3

In this module, we review issues related to accessing and navigating the healthcare system that are relevant to priority populations for PrEP, including men who have sex with men (MSM), women, sero-different couples, adolescents, transgender persons, sex workers and persons who inject drugs or experience coercive sex. For patients, content covers self-advocacy and population-focused concerns and resources for PrEP services. For providers, we discuss the need and approach for tailoring PrEP for priority and often under-served communities with cultural humility.

教学方

Dr. Jason Farley, PhD, MPH, CRNP

Associate Professor

脚本

Hi, am Greg Lucas from Johns Hopkins University. And I'm going to be talking to you today about pre-exposure prophylaxis, or PrEP, which is a new, although as of yet minimally used tool, in the toolkit for risk reduction for people who inject drugs. So by way of outline I'm going to start off talking about the multitude of risks that people who inject drugs are exposed to, of which HIV is a very important one. And given this spectrum of risk, it's important to consider the full menu of tools that can help to reduce risks to individuals who inject drugs. Finally I'll talk about pre-exposure prophylaxis and specifically some of the data, as to how it applies to PWID. And then I'll wrap up talking about the availability, the current availability of PrEP, and the future of PrEP. So, injection drug use is associated with a number of risks, and I have HIV on the top here. But there are other very important risks, including viral hepatitis, drug overdose, which has gotten a lot of attention this year with the epidemic of fentanyl being used in drugs that are injected in many cities in the US. And in fact in Maryland, the state where I live, it looks like for 2016 there will be about 50% more overdose deaths than there were in the prior year. And that's largely attributable to the use of the highly potent fentanyl in drugs that are injected or even taken by non-injection route. Other important risks are skin and soft tissue infections and endocarditis, which is an infection of the heart valve, luckily treatable, but in the absence of treatment is 100% fatal. Individuals who inject drugs are at increased risk for trauma, homicide/suicide, incarceration, and of course there are important psycho-social strains on relations and families that can emerge from drug use. So with these risks there are a sort of a menu of options available to, if not completely ameliorate the risks, at least reduce them. So for hepatitis, there are vaccines for Hepatitis A and B. Unfortunately no vaccine yet for Hepatitis C, which is the version of viral hepatitis particularly important to injection drug users. But there are now highly effective treatments for Hepatitis C, all be it still very expensive. Needle and syringe exchange is extremely important. It's a way to mitigate many of the risks by providing users with a consistent, easy to access and free supply of needles and syringes. And in the absence of that, bleach kits and knowledge on how to use them is recommend to reduce risk of soft tissue infection and transmissible infections. And then importantly is medication assisted treatment, which can help users, particularly those who use predominantly opioid drugs, to reduce or even completely eliminate their use. So the two that are most commonly used are methadone and buprenorphine. There's also now an available antagonist provided in an extended release form called extended release naltrexone. And this is a drug that's useful for people who have detoxed from opioids and want to remain opioid free. And it's been shown in some studies to be effective, although in fairly select populations. Importantly, with the large uptick that we've had in overdose deaths, is providing naloxone, either in injectable form or in nasal spray, to individuals who use drugs or their family members, as a way to potentially save someone from an overdose death. And then for those who are infected with HIV, of course antiretroviral therapy now being recommended to be initiated as soon as individuals are known to be positive, is very important. And then finally our new tool is pre-exposure prophylaxis, which I'll talk about a bit more. But the first point to make is that, although I went through a large list of potential services, it's important to acknowledge that there's tremendous variation in the availability in these services, certainly globally, but in fact even within nations or within states. So, shown on the screen now is a world map that shows the availability of needle and syringe exchange programs. And the color coding of this map isn't very intuitive, but the countries that are shown in pink are countries that have extremely low availability of needle and syringe exchange, almost to the point where they really don't provide any of these services. And that includes Russia, which has one of the highest prevalences of injection drug use in the world and South America. Whereas some of the countries shown in sort of a burgundy color have some of the higher rates of supplying clean needles and syringes, so some of the Scandinavian countries, Australia, and actually Ukraine interestingly. So this variability in services applies to more than just needle exchange. For example, for opioid substitution therapy with methadone or buprenorphine, countries in Western Europe do the best, providing about 61 OST slots for every 100 PWID. Whereas in Russia and some other Eastern European countries, use of this therapy is actually prohibited. Again, despite the fact that there's a very high prevalence of injection drug use in these countries, and in fact injection drug is the main driver of the HIV epidemic in some of these countries. And then similar diversity for providing antiretroviral therapy. Again, we have Western Europe, basically providing antiretroviral therapy to every HIV positive injection drug user. Whereas places such as Russia and Pakistan are treating very small percentages of the HIV positive PWID. The World Health Organization has made a number of recommendations to try to improve outcomes in PWID. And you'll see that a number of these involve very challenging political and social changes. The first recommendation is to end the view of drug use as a criminal behavior and, rather, to treat it as a medical condition. This is extremely important. A lot of countries rely on Draconian incarceration methods for drug users that study after study have shown do little to change the behavior of drug use and actually increase risk of adverse outcomes. The next thing is to expand evidence-based services. So these are the services that I've listed previously, and this,speaks to the, again, tremendous variability among countries and within countries and the availability of these services for people who need it. Then third, addressing institutional stigma and discrimination, obviously a major challenge involving work over years with a consistent application of will. And then finally, countries are advocated to increase their own spending on harm reduction. Many countries rely almost exclusively on external funding for their harm reduction projects, which ends up making them sort of less involved and less invested in the process of harm reduction. So, HIV is a major risk for injection drug use. This slide shows a number of countries with the small green bar showing the prevalence in the general population of HIV for that country, and the blue bar showing the estimated prevalence among people who inject drugs in that country, again for HIV. [COUGH] Okay, well so you've heard about pre-exposure prophylaxis in some of the other presentations. And I just wanted to talk a little bit about how we know that PrEP works. It's been evaluated in a number of large clinical trials. And basically, the design of these trials is to recruit a number of individuals that are at high risk for getting HIV. That's tended to be three groups, men who have sex with men, heterosexuals living in Sub-Saharan Africa, and then there's been a single study of PrEP in PWID, and that was a study conducted in Thailand. Then the individuals recruited to the study are randomized to either receive the PrEP medicine, or to receive a placebo, or a sugar pill. And individuals are followed over time to determine rates of new HIV infections. And studies like this are absolutely critical for us to understand how these therapies work, if they work, and how we can use them more effectively. So on average, these studies have suggested that PrEP reduces the risk of new HIV infections by about one-half, or 50%. And in fact that was almost exactly what the study among PWID in Thailand found. I should note that it was clear in all of these studies that people that did a good job taking their medicines, actually had much greater reductions in their risk. And that many of the people that were in the studies in fact took very few of the pills, and for them, they got very little on the way of risk reduction. So what does that 50% reduction mean? Well, let's say you had a group of 100 HIV-negative people who inject drugs. And let's say it was the case that in the absence of any specific new intervention, if you followed those individuals for one year, about six of them would be likely to get HIV in that next year. What the data from the PrEP study suggests is that, if you were to put all of those people, all 100 of them on PrEP, that then only 3 individuals rather than 6 would get infected within the next year. Okay, well, so what is the current status of PrEP and what are sort of the future options for it? So currently PrEP has been very slow to be implemented. And that has been in all groups, but perhaps slowest in people who inject drugs. So, the World Health Organization set a goal of getting a total of 3 million people, who were at high risk of HIV, on PrEP by 2020. And currently we're only 2% of the way to that goal. Now, at least in the US and in some other wealthy countries, particularly in the last two years there have been efforts to implement PrEP, particularly in MSM populations. But there's been much, much less done among PWID, or even to implement PrEP programs in Sub-Saharan Africa. There are a number of reasons for this that get fairly complicated, but looking forward the hope would be that there is further advancement of the use of PrEP in all of these populations. One thing that people are hopeful about, are long-acting injectable drugs. So all of the PrEP studies, no matter what group they were performed in, showed that people had a lot of trouble taking a pill everyday, particularly individuals that were otherwise completely well and healthy. And adherence was a major challenge, but there are some new drugs on the horizon that can be given via injection and can last one or two months, and there are even potential options that can last up to six months. So, a single injection or a single placement of a small plastic depot preparation might be enough to impart substantial risk reduction for individuals for a prolonged period of time, without the need to take pills everyday. Now, at this point, this is still unproved therapy, but there are trials currently underway looking at the use of these longer-term injectable drugs to prevent HIV in at risk groups. I just want to refer you to the Harm Reduction Coalition website, which has a number of excellent resources, not just for PrEP, but for many of the risk-reduction interventions for PWID. So in conclusion, we've seen that injection drug use has many important risks and I think it's important to consider all of these, HIV is certainly one. PrEP happens to be targeted at the HIV risk, but it doesn't have effects on other risks like overdose or Hepatitis C. So it's important to consider PrEP is just one part of a broader menu of risk reduction interventions that may be used, that may be helpful to the PWID population. And then finally we talked a little bit about the evidence that's specific to PrEP and PWID. At this point it's a single study conducted in Thailand, suggesting about a 50% reduction overall among all comers in the study. But implementation has been very slow for all groups and particularly for PWID, and hopefully that will change in the coming years. I'm just leaving some of my contact information on the screen, thank you very much.